Linköping University Medical Dissertations No. 981
Encouraging Encounters
Experiences of People on Sick Leave
in Their Meetings with Professionals
Ulrika Müssener
Division of Social Medicine and Public Health
Department of Health and Society
Linköping University, Sweden
Linköping 2007
¤Ulrika Müssener, 2007
Cover illustration: Waltie
Printed in Sweden by LiU-Tryck, Linköping, Sweden, 2007
ISBN 978-91-85715-94-7
ISSN 0345-0082
”Det finns saker som man måste vara fackman för att inte förstå.”
Hjalmar Söderberg
CONTENTS
ABSTRACT .................................................................................................................. 5
LIST OF PAPERS ........................................................................................................ 7
TERMINOLOGY......................................................................................................... 8
INTRODUCTION....................................................................................................... 9
Studies on sickness absence .............................................................................. 10
The sickness benefit system .............................................................................. 11
Health..................................................................................................................... 12
Health promotion ................................................................................................ 13
The importance of work ..................................................................................... 14
Return to work...................................................................................................... 15
The perspective of the person on sick leave................................................... 16
Encounters with professionals.......................................................................... 17
Background of the project and the author ...................................................... 18
AIMS OF THE THESIS............................................................................................ 19
METHODS ................................................................................................................. 20
Qualitative and quantitative methods............................................................. 20
How the studies are related ............................................................................... 21
The interview studies..................................................................................... 23
The questionnaire studies.............................................................................. 26
The theoretical study...................................................................................... 28
Ethical considerations ......................................................................................... 29
RESULTS .................................................................................................................... 30
DISCUSSION ............................................................................................................ 35
Methodological considerations......................................................................... 35
Discussion of the results .................................................................................... 39
Experiences of positive encounters.............................................................. 40
Encounters and demographic variables...................................................... 41
Encounters and groups of professionals ..................................................... 42
Encounters and RTW ..................................................................................... 44
A model of theoretical relationships between emotions, empowerment
and RTW................................................................................................................ 44
Implications for practice..................................................................................... 47
Needs for future research................................................................................... 47
General conclusions ............................................................................................ 48
Svensk sammanfattning..................................................................................... 49
ACKNOWLEDGEMENTS ...................................................................................... 52
REFERENCES ............................................................................................................ 54
Due to copyright restrictions the articles has been removed.
ABSTRACT
Background: The recent increase in long-term sickness absence both in
Sweden and many other countries has been met with various attempts to
intensify the use of rehabilitation measures in order to prevent people from
remaining long-term sickness absent. Several actors, among them
professionals in healthcare, occupational health services, and social insurance
are involved in handling issues related to the sick leave of an individual, and
in providing measures to promote return to work (RTW). Identification of the
factors that are related to RTW of the individual is a multifaceted task;
therefore to meet the individual in this process is an essential challenge for
many actors involved. Knowledge is needed about factors that might promote
RTW in order to facilitate future research aimed at designing effective
rehabilitation programs. Such information is of great importance to improve
the work situations of the professionals, to decrease the cost for society, and to
improve the situations for people on sick leave.
Objectives: The overall aim of the work underlying this thesis was to ascertain
whether contacts between professionals and persons on sick leave might be
one factor that can promote RTW, and also to identify different aspects of how
such encounters are experienced by those who are sick listed.
Material and methods: Five investigations were conducted using different
study designs, data, and methods of data analysis. The first two (papers I and
II) concerned interviews with persons with experience of being on sick leave
about positive encounters with professionals. The third study (paper III) was
based on four questions about encounters, which were included in a questionnaire
that was administrated to people who were on sick leave. The fourth study
(paper IV) used a broad questionnaire to examine experiences of positive
encounters, and the final study (paper V) proposed a model of possible effects
of the contacts on RTW.
Results: The first studies (papers I and II) identified different aspects of
positive experiences of encounters. For example, it seemed that important
qualities included being treated with respect, feeling supported, establishing a
personal relationship, and participating in decisions regarding RTW measures.
Several of the interviewees stated that RTW might be promoted by positive
5
encounters. The investigation described in paper III showed that perceptions
of interactions varied with the type of professionals, as well as with
demographics. The respondents perceived their consultations with
professionals within healthcare as most positive, followed by social insurance,
and lastly occupational health services. In general, females, people born in
Sweden, and those who were older, and had a higher education rated their
encounters with professionals as more positive. The main finding reported in
paper IV was that the majority of the participants had experienced being
positively encountered by professionals. Three aspects of such encounters
were stressed, namely being treated with ”competence”, ”personal attention”,
and ”confidence and trust”. The results related in paper V indicated that
theories about empowerment and social emotions could be successfully
applied in this area, after they were specifically adapted to some unique
features of the interactions between sick-listed persons and rehabilitation
professionals.
Conclusions: This thesis emphasizes that being positively encountered by
professionals can have a beneficial impact on RTW after a period of sickness
absence. More research is required to elucidate the interaction between sicklisted persons and professionals who are involved in their cases. Further
studies should focus on how the professionals can be provided with methods
that will help the clients increase their own ability to mobilize and develop
their resources. Moreover, additional knowledge is needed to extend
professional treatment strategies that enhance self-confidence and
empowerment of individuals during sickness absence.
Key words: encounters, sickness absence, sick leave, return to work, client
perspective, health promotion, work.
6
LIST OF PAPERS
This thesis is based on the following papers, which will be referred to in the
text by their Roman numerals I-V:
PAPER I
Klanghed U, Svensson T, Alexanderson A. Positive encounters with
rehabilitation professionals reported by persons with experience of sickness
absence. Work: A Journal of Prevention, Assessment & Rehabilitation 2004; 22(3):
247-254.
PAPER II
Müssener U, Söderberg E, Svensson T, Alexanderson A. Encouraging
encounters: sick-listed persons’ experiences of interactions with rehabilitation
professionals. Accepted in Social Work in Health Care 2006.
PAPER III
Müssener U, Person A, Alexanderson A. A population-based questionnaire
study of how people on sick leave perceive contacts with professionals in
healthcare, occupational health services, and social insurance. Submitted 2006.
PAPER IV
Müssener U, Upmark M, Borg K, Alexanderson A. Positive experiences of
encounters with professionals among people on long-term sick leave.
Submitted 2006.
PAPER V
Svensson T, Müssener U, Alexanderson A. Pride, empowerment and return to
work: On the significance of positive social emotions in the rehabilitation of
sickness absentees. Work: A Journal of Prevention, Assessment & Rehabilitation
2006; 27(1): 57-65.
The published papers were printed with permission from the publishers.
7
TERMINOLOGY
Sickness absence and sick leave: used as synonyms for temporary absence
from work due to reduced work capacity caused by illness, disease or injury.
Sickness certificate: document issued by a physician to confirm reduced
functional work capacity due to illness, disease or injury.
Disability pension: temporary or permanent disability pension granted to a
person who is insured and has a permanent or prolonged reduction in work
capacity.
Sick leave period: a continuous period of sick leave days for which a sickness
certificate is issued.
Sick leave spell: can include one or more consecutive sick leave periods.
ABBREVIATION
RTW: return to work
8
INTRODUCTION
Sickness absence varies among different groups in society and over time. In
the last few decades, long-term sickness absence has increased markedly in
Sweden and other countries (1), both with regard to the number of people on
sick leave and the length of sick leave spells (1-3).
In the 1980s, the levels of sick leave in Sweden increased during a period of
strong economic growth, low unemployment, and high sickness benefits (4).
In the 1990s, many countries carried out reforms in attempts to reduce costs
related to sickness absence and to achieve equal and fair use of sickness
insurance. The sick leave is still high in Sweden. This seems paradoxical,
bearing in mind that, relatively speaking, the Swedish population has good
health, a high standard of living, good working environments, and
considerable longevity (indeed, among the longest life spans in the world) (5).
The consequences of sickness absence are related to human suffering and loss
of welfare, which have an economic impact on individuals and society, and
this complex phenomenon is highlighted in research as well as in the media
and politics.
Back and neck disorders represent one of the most common causes of both
short-term and long-term sick leave and disability pension in Sweden and
other nations (6). In recent years, the levels of sick leave related to psychiatric
diagnoses have increased considerably in Sweden, and this constitutes the
second largest diagnostic group for both sickness absence and disability
pension (7). Cardiovascular conditions such as coronary artery disease and
stroke represent the third most common cause (8). Furthermore, women have
a higher level of sickness absence and disability pension than men (1, 9).
The dramatic rise in sick leave during the later parts of the 1990’s in Sweden,
and the subsequent increase in costs have drawn attention to the issue of sick
leave, and several reports have been published on this subject (4, 10-19).
9
Studies on sickness absence
Studies of sickness absence and disability pension have been conducted from
different perspectives, for example, that of society, the insurance authorities,
the health services, the employers, and the individuals on sick leave (4).
Moreover, most scientific studies have been performed within the fields of
medicine, sociology, or economics (Table 1). Sick leave is influenced by factors
at different structural levels (for example national, local, or individual),
although published studies have mainly addressed those at the level of the
individual or the workplace (4). The factors that have been considered include
for example health status, gender, satisfaction with work, motivation, and
physical and psychosocial work environment (1, 9, 10, 20). So far, we lack the
knowledge needed to understand the complicated associations amongst these
elements (4), although we can conclude that single factors cannot explain the
increasing levels of sickness absence.
The majority of the studies conducted thus far have dealt with risk factors for
sick leave (4), and some have examined physicians’ sickness certification
practices (12, 13, 21), the practice of social insurance officers (22, 23), whereas
few investigations have focused on the consequences of being on sick leave
(24, 25). Furthermore, a number of studies have analysed factors that might
hinder or promote return to work (RTW), and the research underlying the
present thesis belongs to that group. More precisely, the focus here has been
on one factor that might promote RTW among persons on sick leave.
Table 1 summarizes the various aspects of studies on sickness absence (4, 26)
and the aspects that are relevant to the subject of this thesis are indicated in
bold type, that is, the thesis focus on one factor that might effect RTW among
persons on sick leave (how persons experience they have been encountered by
professionals) and this is studied from the perspective of the sick-listed
person.
10
Table 1. Aspects used to classify studies of sickness absence according to the Swedish
Council on Technology Assessment in Health Care (SBU) (4) and further developed
by Alexanderson (26).
Perspective taken
in the study
Scientific discipline
Focus of the study
• Society
• Insurance office
• Health services
• Employer
• Sickness absentees
• Medicine
• Sociology
• Psychology
• Economics
• Law
• Public health
• History
• Philosophy
• Anthropology
• Risk factors for
sickness absence
•Sickness
certification
practice
• Factors that hinder
or promote RTW
• Consequences of
being sickness absent
The structural level
of factors included in
the analyses
• Individual
• Family
• Workplace
• Local
• National
• International
The sickness benefit system
To be able to understand the complexity of sickness absence, it is necessary to
have some knowledge of the sickness benefit system.
The Swedish sickness benefit insurance is part of the social insurance system,
which also includes family insurances, old age pension, and unemployment
insurance. The insurance is public and comprehensive, that is everyone is
insured, regardless of their state of health (4). The sickness insurance is
intended to compensate for loss of income and offer some degree of economic
security when a person has a disease or injury that leads to reduced work
capacity in relation to demands of the tasks done at the workplace (4, 27).
Other European countries have stipulated a clear maximum length of a sick
leave spell, (often 12 months), whereas Sweden has no such limit. The number
of days that a sick leave period can be self-certified varies between countries;
for instance, a sickness certificate is required from day 4 in Germany,
Denmark, and Norway, but from day 1 in France and day 8 in Sweden (17). In
some countries, for instance France, Belgium, and Germany, a medical officer
makes the formal decision as to whether a person has met the requirements for
sickness benefits (17), whereas such judgements are made by social insurance
administrations in Sweden. Although the certifying physicians do not decide
11
whether a person is entitled to sickness benefit, the suggestions they include
on the sickness certificates have a substantial impact on the judgements made
by social insurance offices (4, 19, 22).
The benefit can be paid for full or part-time absence (100%, 75%, 50%, or 25%),
depending on the degree of work incapacity. The first day of sick leave is a
qualifying day. An insured person is entitled to compensation if her/his
annual benefit-qualifying income is more than 9,500 SEK (in 2005) (1,000 EUR).
If it is prognosticated that a person’s work capacity will be reduced for at least
one year, she/he can qualify for disability pension.
The population of Sweden is approximately 9 million, and around 5,76 million
of those people (64%) are of working age; 16-64 years old. In 2006, around
800,000 persons were receiving sickness benefits, of which 300,000 persons
were on short-term or long-term sick leave, and 500,000 persons were on
disability pension. The expenditures for sickness benefits, including disability
pensions, amounted to approximately 90 billion SEK (9,800 billion EUR).
Health
A person’s health status is considered highly relevant when assessing
her/his work ability. Discussions of health include some basic concepts;
such as health, illness, sickness, and disease (28). Illness refers to symptoms
that are experienced by individuals themselves. Disease refers to conditions
that medical science, at a specific time, can diagnose.
According to Boorse (29), health can be described as the absence of disease,
where disease is seen as a dysfunction within an organ or a system in the
body. This biological discourse can be viewed as a reductionist
characterization of health. Opposing views take a broader perspective and
are not anchored in a biomedical context. Pörn (30) and Nordenfelt (31)
have proposed ideas about the concept of health, often referred to as holistic
theories, in which the notion of ability is crucial. It is the relationship
between a person’s abilities and her/his vital goals that determines her/his
health status. Pörn (30) suggests that we should speak of health when a
person’s repertoire, that is the sum total of her/his abilities, matches her/his
profile of goals. Nordenfelt defined health as when it is possible for a
person to realize vital goals (31). In line with these views, disease is a type
12
of internal circumstance that may reduce a person’s health.
So, health is something that can be discussed in a wider context than the
mere absence of disease, since health might also be compatible with some
degree of disease in an individual. In other words, a person can have a
disease and still be healthy in terms of attaining vital goals.
Nevertheless, disease is not an either– or term, instead it can be felt and
diagnosed as more or less serious on a continuous scale ranking from “not
at all” to “very ill” (28). The issue becomes more complicated when sickness
absence and sickness certification are taken into consideration, because then
the need for definite delineation arises. In this context, a person’s work
capacity is either not decreased or it is reduced to a specific degree, and in
the latter case it is also necessary to determine the extent of incapacity (for
full- or part-time sickness absence). Sickness can be viewed as the social
role that is assigned to, or taken by, a person who has a disease or illness in
a certain culture and at a certain point in time. Both disease and illness
concern symptoms and/or conditions in the body either experienced by the
individuals themselves or diagnosed by medical science. This is not the case
for sickness. Sickness is a social position, which involves rights and
obligations, and is part of the relationship between an individual and
her/his environment. Sick leave can be seen as a typical example of sickness
and the sick role, and it gives the sick person a completely new legal status
and a new role with the formal right to be absent from work (32).
This thesis uses a holistic view of health, in other words, health is not
considered to be the opposite of disease, because a person can have a
disease and still be healthy.
Health promotion
Ideas originating from the salutogenic model (33) were applied in all five
studies underlying this thesis. This model was developed by Antonovsky (34),
who used a salutogenic perspective rather than a pathogenic perspective. The
latter is often applied in medical practice and concerns the causes of disease,
whereas the former focuses on factors that lead to or induce health. According
to the original ideas of salutogenesis, in order to promote health, it is more
important to consider peoples’ resources and capacities than to concentrate on
13
risks, poor health, or pathology. The focus is not on what causes disease, but
instead on how people, despite strain or stress, can be healthy. How an
individual feels depends on how that person can handle or control the world.
Furthermore, it is not a question solely for the individual, because the
interaction between people and the structures of society are also important
aspects of health promotion (35).
Research on sickness absence should investigate salutary factors, which are
elements that can promote health, rather than simply involving low risks, for
example studies of risk factors for being sick listed. Any effort to enhance a
persons’ ability to work, including attempts that are not directed at curing the
diagnosed disease, can be seen as an action to promote health. The
rehabilitation of sick-listed persons can be viewed as a health promoting
activity, and such a perspective is applied in this thesis, in particular
considering one factor that might help these people RTW, namely how they
experience the way they are encountered by professionals.
The importance of work
Participation in work life has an impact on the biological and psychological
health of an individual, and paid work is often claimed to be essential for wellbeing. Work is a complex and important feature of our lives, from which we
draw not only an income, but also social interaction and relationships, the
feelings of belonging to a group and being needed, and achieving increased
self-esteem (36-39). Since most of us spend a large portion of our time
working, work has a substantial impact on the organization of our daily lives
(36). Although work is something we actively seek, it is also a source of
injuries and illness or disease (36, 38). However, in the present studies, work
was seen as an activity that makes positive inputs in peoples lives (40), a
viewpoint that has also received considerable attention in research (39, 41).
Working life entails continual and rapid changes (42), which can have a
negative effect on the health of employees and therefore render them at
greater risk of sickness absence. One of the basic ideas when starting this
project was that long-term sick leave can lead to negative social, medical,
and/or psychological consequences for the individual who is sick listed (4), for
example, in the form of loss of income, life structure, social contacts, and social
status.
14
Notwithstanding, inasmuch as participation in work is claimed to be essential
for the well-being of the individual (36, 39), we obviously need to gain a
deeper understanding of factors that promote RTW.
Return to work
The recent increase in long-term sickness absence has been met with various
attempts to intensify the use of rehabilitation measures in order to prevent
people from remaining long-term sickness absent (43-45). It is well known that
the longer someone stays away from work, the more difficult it is for them to
return to the workplace and the higher the risk of entering the disability
benefit system after a period of sick leave.
Promoting RTW is an urgent issue from the standpoints of both costs and
public health, and in most cases the primary aim of rehabilitation measures for
people on sick leave has been to restore or improve the persons’ ability to
work (4). The processing of sickness absence and the provision of RTW
measures involve several actors, such as professionals in healthcare,
occupational health services, and social insurance. Research has been
performed to elucidate the practices of these actors with regard to making
decisions about the right to sickness benefits and measures aimed at
promoting RTW (19). Identification of factors related to RTW by an individual
is a multifaceted task, and thus handling contacts with the person is an
essential challenge for the actors involved in this process. Therefore the
scientific knowledge base concerning management routines and interactions
between all people involved needs to be extended (19).
On the whole, knowledge of what makes rehabilitation measures effective and
of what factors that affect RTW is scarce (23, 45-48). RTW is influenced by
numerous factors at different structural levels, such as the characteristics of the
employee, the job, the workplace, and the insurance and healthcare systems
(12, 49, 50). Unfortunately, few rehabilitation programs have proven effective
in the long run (51-53). No clear determinate for the successful completion of a
program can be generalized to the public at large (54). In fact, in some cases
people long-term sickness absent who have not started any rehabilitation
measures actually have a better prognosis for RTW than those who have taken
part in rehabilitation programs (55, 56). To understand this situation, it is
15
essential to consider the effects of selection: people who do not take part in
rehabilitation might be healthier than those who do.
It is also important to point out that RTW does not necessarily indicate the
degree of successful rehabilitation. Nevertheless, it is of great interest to
identify the factors that hinder or promote RTW in order to facilitate
development of treatment strategies for those persons for whom RTW actually
is considered. As Hansen et al (57) have described it, early discovery of
individual possibilities for and obstacles to a RTW are important as a
foundation for planning rehabilitation measures. Professionals should, for
instance, also pay attention to the individual’s well-being and life situation
when evaluating rehabilitation and RTW measures. An assessment of the
efficacy of rehabilitation for vocational outcome should consider not only
work return, but also stability during follow-up.
To sum up, more knowledge is needed about factors that might promote RTW
so that at a later stage we will be able to proceed with research aimed at
designing effective rehabilitation programs. Such knowledge is of importance
to improve the work situations of professionals, to decrease the cost to society,
and to promote RTW among people on sick leave. The object of the present
studies was not primarily to identify factors that affect RTW, but instead to
ascertain whether encounters between professionals and people on sick leave
might be a factor that can promote RTW, and especially to identify different
aspects of the way such interactions are experienced by the client.
The perspective of the person on sick leave
As mentioned above, most medical research in the area of rehabilitation and
sickness absence is conducted from the perspective of the professional, the
workplace, or society, and rarely from the standpoint of the sick-listed her- or
himself (58). Some studies have illuminated individuals with regard to their
experiences of, and view on, sickness absence, rehabilitation, and factors that
they feel might promote RTW (12, 59, 60). Knowledge is needed from both the
view of professionals and that of the sick-listed person concerning
rehabilitation (58), to be able to understand why so many persons do not RTW
as expected, and also to identify factors that promote RTW.
16
Listening to the individual’s own accounts might give us new angles on what
they perceive as worthless or as successful measures. Furthermore, collecting
data on these experiences can provide a new knowledge base (61). Such
information can complement the previously accumulated research results
concerning other structural levels, such as among employees and in society
(62), and it will establish the importance of considering the experiences of
sickness absentees, when attempting to identify factors that can promote RTW.
In all five studies included in this thesis, the individual was seen as an expert
on her/his own experiences of a specific phenomenon, in this case being on
sick leave, and thus the experiences are discussed from that perspective.
Encounters with professionals
A factor that might promote RTW is how persons on sick leave experience
their encounters with the professionals that are involved in their rehabilitation,
in other words, the quality of the actual meeting between the professional and
the client.
During the preparation for the studies, it was found that very little is known
about the specific qualities of encounters sick-listed persons experience as
positive, or about how such encounters might be promoted. In a previous
study (63) it was found that it is not mainly the type of rehabilitation
measures, but rather how the person on sick leave experience being
encountered by the professionals that is of importance for RTW. Based on this
knowledge, the choice was made to focus on the individual’s experiences in
this context; more specifically, the opinions of sick-listed persons regarding
their encounters with professionals are studied.
Previous studies (64, 65), described and analysed expressions of negative and
positive experiences of encounters with rehabilitation professionals. The
present investigations were conducted from the perspective of health
promotion and therefore focused on how people on sick leave experience
positive encounters with professionals within healthcare, occupational health
services, and at social insurance offices. The main interest was not whether
positive encounters might promote RTW, but instead to investigate what
qualities of the contacts with professional were considered to be positive by
the clients. Few studies have considered this topic, and, to our knowledge,
17
only those cited above, have previously dealt with experiences of such
encounters.
Background of the project and the author
At the end of the 1990s and the beginning of the new millennium, while I was
working actively as an occupational therapist, I became increasingly interested
in the idea of studying the contacts between patients and professionals, as well
as the feelings associated with such contacts and how they might affect the
clients themselves. In work with patients, it became apparent that people are
affected in different ways by how they are encountered by professionals, and
the outcome of rehabilitation is largely determined by the interactions between
patient and caregiver. My interest in this subject continued to grow when I
worked with young people who had undergone extensive trauma that had
changed their life situation. In this later phase of their rehabilitation, the
question of employment arose and along with that the issue of their ability to
RTW after a long period outside the labour market. It became clear that the
possibility of being able to go back to employment depended on, among other
things, how these individuals had been encountered by professionals that had
been involved in their cases, that is, professionals within healthcare, social
insurance offices, employment offices, insurance companies, and other
organizations. A few years later, I had the opportunity to study this
phenomenon on a more scientific level, when I embarked on the research
studies that led to the writing of this thesis. The focus on experiences of
interactions with professionals remained, although the subjects of interest
were no longer patients, but instead people with experience of being longterm sickness absent. The outcome no longer concerned the effects of
rehabilitation, but rather entailed RTW in the long run.
18
AIMS OF THE THESIS
The overall aim of the research was to investigate how persons with
experiences of long-term sickness absence experience their encounters with
professionals in the areas of healthcare, occupational health service, and social
insurance.
The specific aims for the studies were as follows:
- To identify and analyse statements about positive encounters with
professionals made by persons who had been or were long-term sickness
absent (papers I and II)
- To analyse sick-listed persons’ experiences of encounters with
professionals and possible associations of those experiences with some
demographic variables (papers III and IV)
- To suggest and discuss hypothetical relationships between the
experiences of encounters with professionals, health, and RTW during
sickness absence (paper V)
19
METHODS
Qualitative and quantitative methods
Since little research has been done regarding sick-listed persons’ experiences
of positive encounters from professionals, first smaller interview studies were
done, and, thereafter larger questionnaire studies. Both qualitative and
quantitative methods were used to analyse the data. The last study was based
on discussions on theoretical aspects of encounters, and on how positive
encounters might affect RTW.
It was appropriate to combine qualitative and quantitative methods to obtain
further information about the various aspects of contacts, particularly in light
of the very limited number of investigations, and accordingly the inadequate
basic research, conducted in this area. To begin with, interview studies were
done in order to be able to pose detailed questions to fewer individuals about
their experiences of interactions with professionals. Analyses of these
interviews provided a basis for constructing questionnaire items. It was
essential to perform quantitative studies of the mentioned experiences to be
able to collect data from a larger group of persons on sick leave. This method
was also suitable for analysing differences in the perceptions of contacts with
professionals in relation to variables such as gender, age, country of birth,
marital status, level of education, and self-rated health.
20
How the studies are related
The study reported in paper I examined the issue of whether people on sick
leave might emphasize their experiences of positive encounters with
professionals in relation to RTW. The study was explorative and descriptive,
and no specific questions on encounters were asked during the interviews.
Statements about positive encounters with professionals were found in all
groups, which indicate that the interviewees regarded those experiences as an
important factor for RTW.
Based on these initial findings, individual interviews were performed in which
more direct questions were posed regarding experiences of encounters with
professionals (paper II). An inductive and descriptive approach was used to
analyse the data, and a clearer picture of the importance of the contacts
appeared.
In the third study (paper III), four comprehensive and broad questions
concerning encounters with professionals were constructed and included in a
large questionnaire that was sent to 10,000 people on sick leave as part of a
survey initiated by the National Social Insurance Board. Analyses of the
collected data suggested that it is possible to use a questionnaire to obtain
answers to queries about the interactions of interest, and they also revealed
associations with gender, age, country of birth, and level of education.
Based on the results presented in papers I-III, a more comprehensive
questionnaire was constructed that focused on the experiences of interactions
with professionals. The analysis showed that the majority of the respondents
felt they had been positively encountered. The study gave a more detailed
picture of different aspects of such positive experiences, and possible
associations with gender, age, marital status, country of birth, level of
education, part- or full time sickness absence, self-rated health, depressed
during the past year, and reason for sick leave.
Paper V presents theoretical aspects of encounters, along with a
comprehensive model of how positive contacts can affect RTW that is based on
the discussions from the findings described in papers I-III.
21
Figure 1 summarizes how the studies included in this thesis are related.
Figure 1. The relationships between the studies included in this thesis.
Paper I
Focus group
interviews
5 groups
Paper II
Individual interviews
11 interviewees
Paper III
Questionnaire survey
6,171 respondents
Paper IV
Questionnaire survey
5,802 respondents
Paper V
Theoretical study
22
Study design, participants, and collection and analysis
of the data
The interview studies
Paper I
Paper І is based on data from five focus group interviews that were conducted
as part of a large interdisciplinary research project comprising an 11-year
prospective cohort study being conducted by the Division of Social Medicine
and Public Health at Linköping University. That project included investigation
of factors that hinder and promote RTW after long-term sickness absence (66).
The interviewees
Interviewees were strategically chosen from a cohort of all 213 individuals in a
Swedish city, who, in 1985, were 25–34 years of age and had a new sick leave
spell that was due to back, neck, or shoulder disorders and lasted at least 28
days. Interviews with members of the cohort were conducted in 1998. For the
focus group interviews, which provided the data used in the present
investigation, an introductory letter about the project was mailed to 84
strategically selected persons. Sixty-three of those individuals could be
reached by phone and were asked to participate in the study. Thirty-three
persons agreed to take part and were assigned to one of five focus groups. In
all, 18 persons were interviewed.
Drop outs
Thirty of the 63 persons contacted by phone declined to take part, because
they had not had a back disorder for many years, they lacked the time, or they
had other engagements on the dates of the five interviews. One person refused
due to shyness. Fifteen of the 33 persons that agreed to participate did not
show up at the actual interview due to acute illness, or because they could not
get away from work or had forgotten the appointment.
23
The interviews
An interview guide was used that focused on factors that hinder or promote
RTW after a period of sick leave. The interviewer did not initiate discourse
about contacts the interviewees had had with professionals. The task of the
interviewer was to introduce new topics related to factors that affect RTW, to
balance the participation of talkative and quiet interviewees, and to
continually summarize what was said during the interviews. All interviews
were conducted in a public school building and lasted approximately one and
a half hours, and they were audiotaped and transcribed verbatim.
Analysis
A tentative, descriptive and explorative qualitative approach was applied to
analyse the data (67-69). That strategy was considered appropriate because
little work had been done to elucidate the experiences of encounters with
professionals during sickness absence, and hence few definitive hypotheses
existed and not much was known about the nature of the phenomenon (68).
The analysis was performed at the group level, and the object was not to
identify individuals who made certain statements or to note the frequency or
intensity of specific comments.
The three authors individually read and analysed all five transcribed
interviews several times. Each author independently identified statements
about positive encounters with professionals, in other words, interactions that
had led to positive emotions or that were described by the interviewees with
positive words or emotions. The chosen quotations were then compared and
discussed in the group until agreement was reached concerning which
statements to include. Thereafter patterns were searched for in the identified
quotations, categories were formed, and boundaries for categories were
established based on several discussions.
Paper II
Paper II is based on data from 11 individual interviews designed especially for
this project to discern additional aspects of positive encounters.
The interviewees
The interviewees were strategically selected from records at the regional social
insurance office. The inclusion criteria were as follows: persons living in the
municipality of Linköping, who, in May 2002, were 20–60 years of age and had
24
been on sick leave for at least 90 days. In August 2002, an introductory letter
containing information about the project was mailed to 31 persons, and nine of
those agreed to participate. Two other persons who had had long periods of
sickness absence and had heard about the project contacted the research group
and were also included. All 11 of the selected interviewees were between 28
and 59 years of age, and they reported that they had been issued sickness
certificates due to musculoskeletal disorders, mental health problems, or other
disorders.
Drop outs
Of the 31 persons who met the inclusion criteria, 22 chose not to participate.
Among these persons, five women were sick listed due to musculoskeletal
disorders, five women and four men due to mental disorders, and one woman
due to meningitis. Diagnoses were missing for the remaining five individuals
(three women and two men).
The interviews
The 11 participants were interviewed individually in their homes or at the
university. An interview guide containing open-ended questions was used.
The participants were asked to talk about their own positive and negative
experiences of contacts with professionals during their sickness absence and to
explain and describe how they perceived such encounters, i.e. “How were you
encountered?”, “What happened?”, “How did that make you feel?”. They
were also asked in what way positive and negative encounters might affect the
likelihood of their RTW. The introduction and the interview lasted
approximately one hour. The interviews were audiotaped and transcribed
verbatim.
Analysis
An inductive and descriptive qualitative approach was used to analyse the
data (67-69). The inductive strategy was chosen to discover important
patterns, themes, and interrelationships. This method first entails exploring
and subsequently confirming, guiding by analytical principles rather then
rules (68), and it was applied to detect additional aspects of experiences of
positive encounters.
The authors read the interview transcripts independently several times, and
identified statements indicating positive and negative encounters with
professionals, or more precisely, interactions that the interviewees had
25
perceived as positive or negative, or had described in positive or negative
terms. The respondents tended to talk about negative encounters to illustrate
their positive experiences by way of contrast. Some expressions describing
negatively experienced encounters were therefore included to better illustrate
the contacts described as positive and to account for contrasts, although the
focus was still on positive encounters. The selected statements were compared
and discussed by the researchers until agreement was reached about which
comments should be included. Thereafter, patterns were searched for in the
identified quotations, categories were formed, and boundaries for the
categories were established.
The questionnaire studies
Paper III
A comprehensive 50-item questionnaire concerning health, work environment,
life situation, sickness absence, and perceptions of interactions with
professionals was constructed by the National Social Insurance Board. Our
research group was allowed to include four questions about perceptions of
encounters with professionals.
The study population and the participants
The study population consisted of a random sample that included 10,781 of
the total of 26,067 people in Sweden who, in 2002, were 20-64 years of age and
had a new sick leave spell that started during the period 14-27 January and
exceeded 14 days. The sample was drawn from a register of all people on sick
leave compiled by the National Social Insurance Board. The questionnaire was
sent by mail to the home addresses of the participants in May 2002. Data from
6,171 respondents (57%) were available for the analyses.
Drop outs
The external dropout rate was 43%. The number of internal dropouts for the
four questions about encounters was low (4-5%).
26
Analysis
In this study the responses to the following four questions concerning
perceptions of contacts with professionals in healthcare, occupational health
services, and social insurance, respectively, were analysed:
(1) My health problems have been taken seriously by professionals.
(2) Professionals have a correct conception of my health problems and my
life and work situation.
(3) Encounters with professionals have been reinforcing and supportive.
(4) Encounters with professionals have been offensive.
Each of these items (1–4) had four response options: strongly agree, agree,
disagree, and strongly disagree. Respondents were asked to choose one of the
four alternatives to express the degree of concordance. Logistic regression
analysis was used to model the probability of positive perceptions of contact.
Associations with the following demographic variables were analysed: gender,
age, country of birth, and level of education.
Paper IV
Paper IV is based on a questionnaire survey concerning the experiences of
encounters with professionals. The questionnaire was designed for this
project.
The questionnaire
A comprehensive questionnaire about perceptions of encounters with
professionals was constructed, based on the results reported in papers I-III.
The questionnaire included questions on experiences of positive and negative
interactions with healthcare and social insurance professionals, what emotions
such encounters evoked in the respondents, and whether positive and
negative encounters might promote or hinder RTW. The respondents were
first asked if they had been positively encountered by these professionals, the
alternatives were “yes” or “no”. Those who answered “yes” were asked: “To
what extent do the following statements describe how the professional
encountered you?” followed by 19 statements, for example: “She/He treated
me with respect”. Respondent were asked to choose one of four alternatives to
express the degree of concordance between each statement and her/his own
perception, ranging from “to no extent” to “to a great extent”.
27
Study population and the respondents
The study population consisted of a random sample of 10,100 persons in
Sweden aged 20-64, who had an ongoing full-time or part-time sick leave spell
that had lasted for between 6 and 8 months as of 31 January 2003, but were not
receiving disability pension. The sample was drawn from a register of all
people on sick leave according to the mentioned criteria compiled by the
National Social Insurance Board. The questionnaire was sent by mail to the
home addresses of the participants in April 2004.
Drop outs
The external dropout rate for the questionnaire was 42%. Among the
participants who stated that they had been positively encountered, 20% had
not responded to all 19 items under the relevant question for healthcare,
respectively 20% for social insurance.
Analysis
Factor analysis was used to identify factors underlying positive experiences of
contacts with healthcare and social insurance professionals. Multiple logistic
regressions were applied to identify possible associations between the
individuals’ scores for each factor and demographic and other variables.
The theoretical study
Paper V
Paper V presents theories of social emotions and expounds upon the
concept of empowerment in relation to sickness absence and RTW. The
notions of pride/shame and empowerment/disempowerment are elucidated
and discussed, and how these terms can be related in the context of sickness
absence. A simple model of hypothetical relationships between
pride/shame, empowerment/disempowerment, work ability, health, and
RTW was developed to gain a better understanding of how encounters with
professionals might affect RTW.
28
Table 2 summarize information about the participants, and collection and
analysis of the data for paper I-IV. The fifth study (paper V) represents
discussions of social emotions and empowerment, and is further described
in Figure 2 in the result section.
Table 2. Characteristics of the data and methods used in paper I-IV.
Paper
n
Age
Sick leave
diagnoses
Geographical
area
Methods of
data collection
Methods of data
analysis
Municipality
of Linköping,
Östergötland
Focus group
interviews
>28 days
Musculoskeletal
disorders
Qualitative,
explorative and
descriptive
20-60
All
Municipality
of Linköping,
Östergötland
Individual
interviews
Qualitative,
inductive and
descriptive
All
Sweden
Questionnaire
Logistic
regression
analysis
All
Sweden
Questionnaire
Factor analysis,
multiple logistic
regression
analysis
Duration
of sick
leave
spell
I
18
II
11
25-34
>90 days
III
6,171
20-64
>14 days
IV
5,802
20-64
6-8
months
V
Theoretical study
Ethical considerations
All studies were approved by the Research Ethics Committee of the Faculty of
Health Sciences of Linköping University, and the Sick Leave Registration
Project of Östergötland was also authorized by the National Data Inspection
Board.
29
RESULTS
Paper I
The first study dealt with the way that long-term sick-listed persons described
their experiences of positive encounters with professionals. Such descriptions
were recorded in all the five focus groups, and were made by all but two of the
interviewees. One of the main findings was that, when asked about factors
that hinder or promote RTW, the participants actually mentioned the
importance of being positively encountered.
A general observation from the analyses was that interviewees frequently
attributed their positive experiences of contacts with rehabilitation
professionals to sheer luck. More specifically, some participants stated that
they had gone through periods of interactions with various professionals that
had not been helpful in solving their problems, and then, purely by chance,
they met a professional who they experienced as providing a positive
encounter.
Respectful treatment appeared as one of the main categories of positive
encounters. Being believed in, being taken seriously, being acknowledged as
being in the right and being listened to were pointed out by the interviewees
as essential elements of high-quality interactions with a positive emotional
content. Moreover, the participants emphasized that it is important that a
professional believes in and shows respect for the client’s problem, and also
believes in her or his capacity to solve or handle the difficulties at hand.
Supportive treatment, the second major category of positive experiences of
encounters, involves the importance of being strengthened and encouraged by
the professionals. This included showing personal interest, that is, when a
professional provided treatment beyond expectations. Another aspect was
when professionals took an advocate or a spokesman role in conflicts with
other professionals or with relatives, or was easy to get an appointment with.
30
Paper II
In the study described in paper II more directed questions about interactions
with professionals were posed, and the results gave additional and more
detailed knowledge about various aspects of the encounters.
Being treated with respect, feeling supported, establishing a personal
relationship, perceiving demands as well-balanced, and having participated in
decisions regarding rehabilitation appeared to be important qualities. The
interviewees indicated that when professionals treated them in a respectful
and supportive manner, they felt relieved, strengthened, improved, and
helped.
A further dimension of the results concerns the issue of whether the contacts
might affect RTW. Several of the interviewees believed that RTW might be
promoted by positive encounters and hindered by negative encounters. Some
of them claimed that if professionals did not listen, it might have a detrimental
impact on the individual’s self-confidence, which in turn might delay RTW.
Paper III
The study discussed in paper II was a first attempt to use a questionnaire to
investigate a larger population with regard to the ways that people on sick
leave experience their interactions with professionals. An important finding
was the fact that most participants answered the type of questions included in
the questionnaire and the answers clearly varied.
The analysis showed that the perception of contacts varied greatly with type of
professionals and with demographics. The respondents perceived their
encounters with professionals within healthcare as most positive, followed by
those in social insurance and occupational health services. In general, females,
people born in Sweden, those who were older, and those who had a higher
education rated their interactions with professionals as more positive than did
males, people born in other countries, and those who were younger, had a
lower education, and a lower income.
The results of this investigation were very useful when preparing for the next
questionnaire study on this subject.
31
Paper IV
In this study (paper IV), a broad questionnaire was administered to a large
sample, and this survey represents the largest that has been performed thus
far in this area of research. The majority of the respondents had experienced
being positively encountered by professionals.
The factor analyses identified three factors, namely, being treated with
“competence”, “personal attention”, and “confidence and trust”. “Treated me
with respect”, “listened to me”, and “was nice to me” were the items that most
of the respondents agreed with to the largest extent. Results from the multiple
logistic regressions analyses indicated that women, people born in Sweden,
and those with good self-rated health who had experienced their encounters
as positive did so to a greater extent than did men, people born in other
countries, and those with low self-rated health. The largest differences in the
ways the participants perceived positive encounters from professionals were
found in relation to country of birth and self-rated health.
Paper V
In paper V an effort was made to propose a model of how encounters with
professionals might influence RTW. Furthermore, concepts such as social
emotions and empowerment were discussed in the context of rehabilitation
of persons on sick leave. Social interaction that induces positive selfevaluation contributes to the emotion of pride; pride contributes to
empowerment; and empowerment contributes to enhanced work ability
and thereby to strengthened health. Contrariwise, social interaction that
induces negative self-evaluation contributes to the emotion of shame;
shame contributes to disempowerment; and disempowerment contributes
to weakened work ability and to ill health (Figure 2).
It is suggested that the emotional dimensions involved in meetings between
people on long-term sick leave and professionals may be more important
variables in the rehabilitation process than has previously been recognized.
32
Figure 2. A simple model of hypothetical relationships between social emotions,
empowerment/disempowerment, health, and RTW.
Empowerment
Pride
Sickness absence
Interaction
with
professionals
Positive
selfevaluation
Options for RTW
promoted
Negative
selfevaluation
Shame
Weakened
work capacity
and health
Strengthened
work capacity
and health
Disempowerment
Disability
pension
33
Table 3. Research questions, object of the analysis, and general results of the five
studies.
Paper
Research questions
Focus in the analysis
Results in general
Do persons with experience of
sickness absence mention
positive encounters with
professionals when asked about
what effects RTW? If so, what
types of positive encounters do
they talk about?
What aspects of positive and
negative encounters do persons
with experience of sickness
absence emphasize when asked
about their meetings with
professionals?
Do sick-listed persons believe
that such encounters might
affect RTW?
How do persons with experience
of sickness absence answer
statements on encounters with
professionals? Do experiences of
encounters differ between
groups of professionals?
Are positive and negative
encounters associated with
demographic variables?
All statements about
positive encounters with
professionals.
Positive encounters were
mentioned in all groups.
Important aspects included
being treated with respect and
given support.
Statements about how they
experienced positive
encounters from
professionals, and whether
positive encounters might
affect RTW.
IV
What aspects of positive
encounters with healthcare and
social insurance do persons with
experience of sickness absence
emphasize?
Are there relationships between
experiences of positive
encounters and demographic
and other variables?
V
To discuss aspects of
pride/shame and
empowerment/disempowerment
in the context of encounters with
professionals during sickness
absence and importance of this
for RTW.
Experiences of positive
encounters with healthcare
and social insurance staff.
Associations with gender,
age, marital status, country
of birth, education, part- or
full-time sickness absence,
self-rated health, depressed
during the last year, reason
for sick leave.
Relationships between
social emotions and
empowerment in the
context of being on sick
leave.
Experiences of positive
encounters were categorized
as follows: being treated with
respect, feeling supported,
establishing a personal
relationship, perceiving
demands as well-balanced,
participating in decisions
about rehabilitation.
Sickness absentees
experienced encounters with
professionals most positive in
healthcare, followed by social
insurance offices, and
occupational health care.
Females, people born in
Sweden born, those who were
older, and those with a higher
education were most positive
about their interactions with
professionals.
Three important factors of
positive encounters: being
treated with competence,
personal involvement, and
confidence and trust.
Women, people born in
Sweden, and those with good
self-rated health had higher
odds of rating positive items
more positive.
Development of a model of
how social interaction with
professionals might affect
sickness absentees’ selfevaluations and RTW.
I
II
III
Differences between
professionals within
healthcare, occupational
health services, and social
insurance.
Associations with gender,
age, country of birth, and
level of education.
34
DISCUSSION
This thesis discusses the experiences of people on long-term sick leave in
regard to positive encounters with professionals. The results of the first study
(paper I) showed that positive encounters are an important factor when
persons who have been on sick leave are asked to identify factors that promote
RTW. Further work provided more detailed information about the different
aspects of interactions with professionals (paper II), and also showed that the
way the contacts were perceived by people on sick leave varied in relation to
demographics, and group of professionals (paper III). The factors underlying
the positive experiences of encounters and associations between those
perceptions and demographic and other variables are presented in paper IV.
The results reported in paper V point out some theoretical relationships
between social emotions and empowerment in the context of rehabilitation
during sickness absence.
Methodological considerations
Two of the strengths of the approach used in the current research were that
several different types of data collection were used, and the analyses were
both qualitative and quantitative in nature. This design was chosen to gain a
broader understanding of how people on sick leave experience their
encounters with professionals. Among others, Krause (70) has indicated that it
will probably be necessary to combine qualitative and quantitative research
methods in order to bridge the knowledge gap in this area of research. The
methodology used in the present studies was elected in an attempt to narrow
that gap.
Another advantage of the design was that the studies were conducted from
the perspective of people on long-term sick leave (61). It has been maintained
that the experiences of the individuals, also called lay knowledge, are
underutilized in research on the RTW process, and most earlier studies have
often not employed this potential knowledge base (70). Thus, by using such
perspective, we have contributed important data to this field.
35
The study related in paper I included statements also about employment
agency and social welfare staff. That was done because statements about
interactions with these groups of professionals had been made in some of the
focus groups, and, at that stage in the project, interactions with all types of
professionals were of interests. The later studies (papers II and IV) were
limited to healthcare and social insurance professionals. The work described in
paper III, also included occupational health services.
An additional strength of the present approach was that, instead of starting
from a formulated hypothesis, we studied a phenomenon (sick-listed persons’
experiences of encounters with professionals), without making any prior
assumptions (paper I). When prior knowledge is lacking within an area of
interest, the researchers’ expectations can be less biased with regard to the
findings (68).
It seemed that the interviewees frequently recognized each other’s experiences
and could associate them with similar perceptions, which also led to a
willingness to share personal experiences. To obtain more explicit data on that
topic, we used more direct questions in the second study. The approach in that
case was to identify aspect that appeared to be important for RTW, rather than
to analyse detailed aspects of positive encounters. Furthermore, the
communication within the focus groups encouraged the interviewees to share
and discuss their own experiences, and to remember events that had occurred
many years ago. This strategy provided helpful information, and the results
were also used to construct more directed questions on encounters with
professionals (paper II).
Individuals with shorter sickness absence (>14 days), as well as persons with
long-term sickness absence (>6 months) were included. This was done to
ensure that there would be contrast and variation in their experiences of being
on sick leave and factors affecting RTW.
Validity in qualitative studies is closely associated with the choice of design
and with the method used to collect data (68). The validity, meaningfulness,
and insights generated by qualitative inquiry have more to do with the
richness of the information held by the people being interviewed and the
analytical capabilities of the researcher, than with the sample size. Therefore, it
is difficult to choose the number of interviewees. That selection can be guided
by time and resources, together with the quality of the information received
(68). The data obtained in the present interviews were of good quality and
36
gave a broad and distinct picture of the situations of the interviewees. Several
steps were taken to ensure the validity of the results (71). The interview guides
had previously been tested in a pilot study (72) and one other investigation
(not published) to confirm that the questions were correctly understood.
Moreover, the interviewers were trained group leaders and had experience of
working with both individuals and groups of persons suffering from pain
disorders, and had also conducted field investigations of clients receiving
healthcare.
Use of an interview guide in semi-structured interviews (paper II), provided a
satisfactory framework that proved useful in that it helped the discourse
towards positive and negative experiences of contacts with professionals, but
still allowed the interviewees to express themselves in their own ways. In both
paper I and II the authors read the interview transcripts independently many
times. Quotations were first selected separately and then compared and
discussed by all authors. Statements for which consensus could not be reached
as to whether they indicated positive encounters were excluded. Quotations
were also excluded if they expressed satisfaction or dissatisfaction with having
been given a medical examination or treatment, such as X-rays or surgical
procedures. This was done so that the focus would be on encounters with
professionals, not the evaluation of the results of medical treatments. For the
same reason, experiences from meetings with employers, colleagues, friends,
and families were also excluded.
The authors differed with regard to age, gender, and educational background.
During the project, several seminars were held to discuss the data and the
results of the analyses in order to enhance validity.
An advantage of starting with small samples was that the results could be
used to construct questions about contacts with professionals (paper IV). As
mentioned, the purpose of study III was to use a questionnaire to investigate
experiences on encounters in a large sample (10,000 persons). The
questionnaire was developed by the National Social Insurance Board, and it
included 50 items and was designed for analyses of work environments, life
situations and sickness absence. Our research group had the opportunity to
add four questions about perceptions of encounters with professionals, and
these questions were based on the results of our previous studies (papers I and
II) and another investigation that addressed the same area (63). The survey
had two particular advantages: a large and population-based data set was
37
available for the statistical analyses, and the four items that were analysed
were included in a larger questionnaire. Therefore, it is not likely that the
dropout rate was systematically related to the items evaluated in the present
work. The design was useful to find differences between how the sick-listed
persons experienced being encountered in relation to both different groups of
professionals and demographic variables. Such knowledge can not be
obtained by qualitative methods. Another asset of our approach was that it
facilitated further development of the questionnaire items described in paper
IV.
The strengths of the study reported in paper IV include the substantial size of
the sample, which, to our knowledge, represents the largest and most
comprehensive study thus far to examine how sickness absentees experience
their interactions with professionals. Another strong point is that the sample
was based on a population, not on a specific diagnosis, occupation,
geographical area, workplace, or clinic, as is often done in studies of this type.
The sample was drawn by the National Social Insurance Board, which has
years of experience in the area and compiles highly accurate data registers.
Face validity can be claimed, since the questionnaires was developed by
professionals and researchers who have worked for many years with people
who are on sick leave or undergoing rehabilitation, and/or have investigated
sickness absence. In addition, the questionnaire items were constructed on the
basis of previous findings of qualitative (64, 73, 74) and quantitative studies
(65), and clinical experiences and theoretical considerations (75). Early
versions were tested in small pilot studies and then further developed after
discussions with other researchers in the area. It is difficult to say whether the
use of more directed and specific questions concerning encounters is the best
method to gain knowledge in this area. We posed questions about one meeting
during which the respondents experienced being positively or negatively
encountered, instead of asking how often they had experienced such
interactions. Thus, our interest was focused on what they actually experienced
during the meetings, rather than on how common those experiences were.
A limitation to the project design was that the dropout rate was relatively high
(around 42%) in the questionnaire studies (papers III and IV), which,
unfortunately, is now a fairly widespread phenomenon in large questionnaire
surveys.
38
Factor analysis is an explorative method that is in some ways similar to a
qualitative approach, since it is possible for the researchers to categorize
recurrent patterns in the material. This methodology was suitable for further
development of our earlier interview studies. The multiple logistic regression
analysis helped ascertain how the individuals scored each factor in relation to
demographic and other variables.
Aspects of time can constitute problems in both interview and questionnaire
studies, and the current results might have been affected by recall bias. In the
first study (paper I), the interviewees were chosen from a cohort defined for
the year 1985. In 1998 the members of the cohort were asked about factors that
they thought might affect RTW. Some of these individuals were not on sick
leave at that time, and they talked about meetings with professionals that
happened many years ago. It may have been difficult to remember what had
occurred during the meetings and how they had perceived the interactions
with the professionals in 1985. However, the discussions in the interview
studies (papers I and II) did not indicate that they had difficulties in recalling
the meetings. Instead it seemed that even though some of the consultations
had occurred many years ago, they still evoked strong feelings and were well
recollected. The same was probably true for the respondents in the
questionnaire studies (papers III-IV). In the focus group interviews (paper I),
the group interaction encouraged the interviewees to share and discuss their
own experiences, and also to remember events that had taken place long ago.
Although the studies varied in terms of the participants and the methods used
to collect and analyse data, the results they provided are in several ways
similar and thus support each other. Because of the different study designs, it
is difficult to directly compare the findings, but then again that was not the
aim of the research. Instead, each investigation had a specific objective, and
each study was constructed based on the results of the previous work.
Discussion of the results
Past experiences and expectations, along with other circumstances, such as
family issues or how clients are able to deal with situations, might influence
how clients experience their contacts with professionals. However, the
purpose of the studies included in this thesis was, specifically to illustrate the
personal accounts of encounters with healthcare and social insurance
39
professionals reported by people on sick leave, not to identify or discuss the
reasons why they perceived the encounters in a certain way.
Experiences of positive encounters
The results indicated that interactions with professionals induce either positive
or negative emotions in the client. The interviewees described how important
they felt it was to be respected, listened to, taken seriously, and encouraged
and supported by professionals. Another element of high quality encounters
that they looked upon as essential was that the professional should believe in
the client’s capacity to solve and handle the problems in question. It was also
considered to be important that professionals played the role of an advocate or
a spokeperson in conflicts with other professionals or with relatives.
Moreover, the participants used positive words to describe professionals that
departed from their roles as experts and talked about things other than
medical problems and thereby became involved in a more personal way. In
addition, some of the interviewees stressed that it was vital that professionals
encouraged them to take part in making decisions regarding rehabilitation,
and made well-balanced demands.
The importance of interaction in healthcare is often emphasized, although
most studies have been interested in interactions between physicians and
patients or nurses and patients (76-85). In these studies the subjects mentioned
being taken seriously and believed in (83, 86), and listened to and given
information (78, 84) as features of positive contacts. Studies have also found
that good qualities of the professional might influence the feeling that the
medical condition has improved (85), and in that way lead to more effective
treatment (78, 84).
Many studies on this topic have used the term satisfaction as the primary
outcome when analysing the ways that clients/patients rated the quality of
interactions or medical treatments. Furthermore, degree of satisfaction has
often been measured soon after the encounters. Our results indicated that
rehabilitation efforts and interactions between professionals and sick-listed
persons are complicated matters that require substantial skills and knowledge
on the part of the professional. To consider only, for example, client’s
satisfaction is not enough when trying to identify important aspects of
interaction with professionals and effects on RTW.
40
It should also be mentioned that analyses of the contacts between patients and
physicians or nurses cannot always be compared with studies of encounters
between people on sick leave and professionals, due to the different
perspectives and objectives. The current studies explored the way that people
perceived positive encounters also with other types of professionals whom
they have met during their sickness absence, and the sick leave spell covered
periods of at least 14 days up to eight months. The purpose was to provide a
picture of the way the participants themselves described their positive
encounters.
Encounters and demographic variables
In the first questionnaire study (paper III), contacts with professionals were
rated as more positive by women, people born in Sweden, older persons, and
those with a higher education than by men, younger people, and those with a
lower education. Östlund et al (65) found that women with experiences of
being on sick leave perceived their contacts with both social insurance officers
and healthcare professionals as more supportive than did men. However,
Ahlgren et al (87) observed quite the reverse: compared to men, women more
often felt that they were distrusted when asked about their experiences of
rehabilitation during sickness absence. By comparison, Bäckström (11) studied
people on sick leave and found that women more often experienced being
ignored, whereas men felt that they were offered relevant measures.
The results regarding gender-related experiences of contacts found in the
investigations included in the present thesis are not completely comparable
with the findings of previous studies. The main reason is that some of our
findings (papers I and IV), concerned only those who had had positive
encounters (i.e., negative experiences were not analysed), whereas the other
studies mentioned above considered both positive and negative aspects of
such contacts. Irrespective of the research methods used, it is difficult to
determine whether women and men are actually treated differently, or if and
how these issues affect each other. The same is true for age differences. The
older respondents were more positive about their encounters with
professionals than the younger ones were. Again varying expectations might
be an explanation for this finding, and it seems likely that younger individuals
will have comparatively higher expectations and make greater demands.
41
Respect for the professionals is another factor that might have an impact on
how contacts are perceived. Older people probably have greater respect, and
thus the participants in that age group in our studies may have reported their
experiences as more positive because they did not question the treatment they
received. It is difficult to explain the finding that people with a higher
education perceived interactions with healthcare professionals as more
positive compared to what was indicated by those with a lower or average
level of education. Presumably, educated people might find it easier to
communicate with healthcare professionals, who are also more educated. The
fact that contacts with professionals in general were rated as more positive by
native Swedes might be due to language difficulties, meaning that native
Swedes are actually treated more congenially (88).
Encounters and groups of professionals
More persons stated that they had experienced positive encounters with
healthcare professionals in both studies where that question had been placed
(paper III and IV). The results given in paper III showed that, in general,
interactions with professionals were experienced as most positive in
healthcare, followed by social insurance and occupational health services.
Also, the investigation described in paper IV indicated that more individuals
had experienced positive encounters with healthcare professionals than with
social insurance officers. Moreover, the mean rating was higher for each item
concerning positive contacts with healthcare professionals in that study. Only
those who stated they had had positive meetings were included in the analysis
reported in paper IV, which is why it is not possible to compare the results
with the findings related in paper III.
It is, however, notable that the people on sick leave generally responded in
more positive terms with regard to healthcare compared to occupational
health services. Logically, the staff of occupational health services should have
a comparatively better understanding and a more comprehensive picture of
the situations of their clients, since they follow the individuals in their
workplaces and, hopefully, they know more about those environments.
In the investigation discussed in paper IV, a relatively large number of the
participants did not respond to the question concerning experiences of
positive encounters with social insurance staff. We do not know whether this
42
partial non-response rate was due to the participants never having been in
contact with such staff, or if they had met them but the contacts had not been
positive.
Healthcare and social insurance professionals have rather different roles in
their contacts with sick-listed persons. The staff in the latter organization serve
as gate-keepers that are supposed to determine whether clients fulfil the
requirements for receiving benefits and additional RTW measures (89).
Healthcare professionals on the other hand help and treat their patients and
sometimes also play the role as the patient’s advocate (21). The expectations
and previous experiences of different individuals vary, and they might also
affect how interactions are perceived. Furthermore, even though a long sick
leave spell (in paper IV at least six months) was used as an inclusion criterion
in order to increase the chances that the respondents would have met with
social insurance professionals, it is possible that not everyone had had such
contact, and therefore did not answer the question. Another reason why the
probability of having experienced a positive interaction appeared to be greater
within healthcare is that all people on sick leave meet this category of
professionals more often (e.g., to obtain a sickness certificate).
In an investigation of being on sick leave (90), it was found that professionals’
attitudes and behaviour were important for RTW. The interviewees indicated
that they were dissatisfied with the treatment and support they had received
from many professionals, such as the social insurance staff. In general, the
participants implied that they were satisfied with the medical treatment
provided by healthcare professionals, but they felt they had to wait too long
for those services (90). Again, the term satisfaction was used. The behaviour of
work supervisors has also been mentioned as a determinant of RTW, and a
recent study indicated that supervisors should communicate more frequently
with employees during sickness absence, and also hold follow-up meetings
more often (91).
Our results can not be used to discuss the behaviours of the professionals in
question, because they can only account for and be used to deliberate about
the way the study participants experienced their meetings with the professionals.
43
Encounters and RTW
The primary aim of this research was not to investigate how encounters might
promote RTW, but to identify different experiences and aspects of positive
encounters with the professionals. Nevertheless, the issue of improving RTW
can be further elucidated by using some of the questionnaire data compiled in
paper IV, along with other methods and participants who have actually
returned to work. When interviewees were asked what they felt hindered or
promoted RTW, they mentioned the importance of contacts with professionals
(paper I). They also indicated that when they were treated with respect and
support by professionals, they felt relieved, strengthened, improved, and
helped. Several of the interviewees stated that RTW might be promoted by
positive encounters and hindered by negative interactions. Also, some felt that
professionals who did not encounter their clients in a positive manner might
have a negative impact on the individual’s self-confidence, which in turn
would affect RTW (paper II). Hansen et al (90) explored what sick-listed
persons perceived as important in the process of RTW, and they found that
support and participation in the sick leave process were considered to be
essential. They also concluded that the professional’s ability to discover the
individual’s need for support is very valuable in that context (90).
Of course RTW is as mentioned also influenced by several other factors at
different structural levels. However these factors are not further described
here.
A model of theoretical relationships between
emotions, empowerment and RTW
When starting the research leading to this thesis, it became apparent that more
basic knowledge was needed to be able to construct theoretical frameworks.
Therefore, the first studies included in the project were descriptive, inductive,
and exploratory in nature, and were not based on specific theories or
theoretically derived hypotheses. Nonetheless, it is obvious that more work is
required to develop theoretical contextualization in this area, and that
theoretical concepts have to be elaborated and applied in order to improve our
understanding of what psychological and social processes and mechanisms
that might be involved. For example, it would be relevant to answer questions
concerning the way that the contacts with professionals affect the persons’
44
self-image and self-evaluation. While conducting the present studies, it
became clear that little is known about the long-term social and psychological
consequences of sickness absence.
The first investigations (papers I-II) indicated that how sick-listed persons are
encountered by professionals is of great importance, and that those clients
may experience such encounters as positive or negative, which may influence
the outcome of the rehabilitation process. Discussions and research concerning
such social and psychological aspects of interactions would therefore be
improved by theoretical contextualization, which in turn would guide
empirical research.
We found that theories on social emotions, (e.g., pride and shame) and on
empowerment could be fruitfully applied in our research. However, such
general theories may have to be specifically adapted to some unique features
of interactions between people on sick leave and professionals, and thus it is
somewhat difficult to apply existing theories. An attempt was done to examine
and apply such theories (paper V), and the following discussion is based on
the assumptions that were made.
Pride and shame are emotions that are claimed to be of particular importance
in interactions with others. Shame tends to make us want to hide, to withdraw
from social interaction, to be alone, and to refrain from displaying our
emotional state, whereas pride makes us want to be seen and heard, and to
come closer to and increase our interaction with others (92).
The terms pride and shame have been highlighted in discussions by our
research group. In this thesis, instead of pride, the broader term positive
emotions is used, and thus the opposite term is negative emotions, here used
instead of shame. Since a salutogenic perspective was applied in our studies,
the following discussion concerns positive social emotions.
According to Scheff (93, 94), feelings of pride can occur only in social contexts,
when you are evaluated in the eyes (real or imagined) of others, and those
feelings are very closely linked to your self-perception and self-esteem.
Therefore, it seems plausible that social emotions will be more readily evoked,
and more deeply felt, in interactions with those on whom you depend, or who
have some measure of power over your future or well-being, such as the
various kinds of professionals you meet when you are on sick leave. These
45
professionals often have a decisive influence over the course and the outcome
of the rehabilitation process, and hence are therefore important actors in the
proceedings related to sickness absence.
The notion of empowerment has gained an ever-widening area of application
in recent decades. It has come to be regarded as a method or strategy or
remedy that is applicable in almost each and every part of social life where
there is a desire to in some way improve the situation of some group or
category of individuals. The term empowerment can thus be found in contexts
involving specific categories of human beings, such as blacks (95), gay people
(96), people with AIDS (97), students (98), nurses (99), women (96), the elderly
(100), patients (101), employees (102), and many other groups.
After further theoretical development, empowerment can be used to point to
some dimensions of what seems to be necessary to enable people to find the
strength and control that is required for RTW after a prolonged period of
sickness absence (75). It is important that professionals within healthcare,
occupational healthcare and social insurance, not only help the sick-listed
person capable of RTW in a physical sense, but that they also make her/him
want to achieve that goal and perceive RTW as a meaningful option.
Therefore, it is highly important to strengthen the sense of control of the client,
and contribute to a raised level of self-esteem and self worth, and thereby
enhance empowerment. The relationship between positive emotions,
empowerment, and health are apparent. The ways a person is encountered by
professionals might have an effect on how that individual uses her/his internal
resources in a wider sense.
To summarize, social interaction that induces positive self-evaluation might
contribute to the social emotion of pride, (here called positive emotions).
Furthermore, positive emotions might add to empowerment, and
empowerment might lead to enhanced work ability and along with that
improved health.
The term empowerment has, as mentioned earlier, been used in studies on
barriers and facilitators of RTW. Friesen et al (45) found in interviews with
stakeholders that interactions that allow and encourage worker participation
and empowerment are vital to the well-being of the worker and her or his
ultimate RTW. This might be achieved by improved communication and
should be a goal for many professionals. Millert et al (42) raised the question
46
of whether empowerment can be a solution to meet the perils of modern day
working life, and they concluded that empowerment and individual control
are key factors in the concept of successful rehabilitation. By mobilizing
clients’ internal resources, the individuals are better equipped to face the
challenges that arise during the rehabilitation process, and, if better prepared,
they are more likely to return to the work force. A number of studies have also
measured empowerment in working life. Arnesson et al (103) identified and
described such questionnaires, and they concluded that research is required to
better explain the interplay between conditions at work and empowerment
and health.
Implications for practice
This thesis highlights the importance of being positively encountered by
professionals during sickness absence. In particular, the results suggest that
professionals need to respect and encourage their clients in order to establish a
relationship that can promote the sick-listed persons’ ability to RTW. When
working with persons who are on sick leave it may be beneficial for
professionals to consider that they have a responsibility in that the way they
act towards their clients can affect the ability of those individuals to manage
RTW. Professionals need to develop their awareness of, and skills in,
stimulating their clients to develop their own plans to improve their situation.
A clinical implication elucidated in this thesis is the need for professionals to
be conscious of, and further develop, their communication skills. The client
should be given information, and be treated with respect and concern
according to current healthcare legislation (104). The role of the client, her/his
responsibility and own participation in treatment should be better clarified
(105). Professionals involved in the rehabilitation process related to sickness
absence should encourage their clients in this matter.
Needs for future research
More research is needed to elucidate the interactions between people who are
on sick leave and the professionals involved in their cases. Further studies
should focus on how the professionals can be provided with methods that can
help increase the clients’ own ability to mobilize and develop internal
resources. Additional knowledge might facilitate the design of treatment
47
strategies that will enhance self-confidence and empowerment during sickness
absence.
The hypothetical relationships between empowerment, work ability, and
health in the context of work-oriented rehabilitation should be investigated
in depth and theorized, and also tested empirically. Should these
relationships prove to be true, the information obtained could be effectively
incorporated into the organizing and structuring of rehabilitation efforts
and in the training of professionals.
Additional research should also be performed to determine how experiences
of encounters with professionals might affect RTW.
General conclusions
Information about the factors that might promote RTW should be collected so
that it can later be used in research projects and to design effective
rehabilitation programs. Such knowledge is highly important for improving
the work situations of professionals, helping people on sick leave to RTW, and
decreasing the cost to society. The present studies were not focused primarily
on identifying factors that affect RTW. Instead, the objective was to determine
whether interactions between professionals and people on sick leave might be
a factor that can promote RTW, and, in particular, to identify different aspects
of how such encounters are experienced by sick-listed persons. For example,
being supported, believed in, taken seriously, and treated with respect are
important qualities exhibited by the professionals during meetings with their
clients. Several of the interviewees believed that such encounters might have a
positive impact on their self-confidence, which in turn might promote RTW.
Perceptions of contacts varied with the type of professionals and with
demographics and other variables. In general, women, people born in Sweden,
individuals with good self-rated health, those who are older, and those with a
higher education and income rated their encounters with professionals as
more positive than did males, people born in other countries, individuals with
low self-rated health, those who were younger, and those with lower level of
education or lower income. Moreover, encounters with healthcare
professionals were rated as more positive than interactions with social
insurance staff.
48
Svensk sammanfattning
Sjukfrånvaro är ett komplext problem med många konsekvenser för både
individen och välfärden, relaterat till mänskligt lidande såväl som till
nationella ekonomiska aspekter. Sjukfrånvaron har ökat både i Sverige och i
andra länder och vi behöver mer kunskap om vad som främjar återgång till
arbete bland sjukskrivna personer. Tidigare studier om sjukfrånvaro har
mestadels fokuserat på riskfaktorer för sjukskrivning såsom kön, sjukdom,
arbetstillfredsställelse, motivation, psykisk och fysisk arbetsmiljö,
försäkringssystemets och arbetsmarknadens utformning etc. Faktorer som
påverkar den sjukskrivne att återvända till arbete är inte studerade i samma
utsträckning. En aspekt som kan ha betydelse för detta är hur professionella
personer bemöter den sjukskrivne.
Syftet var att identifiera och analysera sjukskrivna personers upplevelser av
positivt bemötande från professionella inom hälso- och sjukvård,
företagshälsovård och försäkringskassa. Syftet var vidare att analysera om
upplevelser av positivt bemötande kan vara relaterat till kön, ålder, civilstånd,
födelseland, utbildningsnivå, hel– eller deltidssjukskrivning, självskattad
hälsa, depression under det senaste året samt orsak till sjukskrivning. Ett
ytterligare syfte var att få kunskap om sjukskrivna personer upplevt sig blivit
mer eller mindre positivt bemötta beroende på vilken grupp av professionella
man träffat.
I avhandlingen ingår fem olika studier som baserats på data från fyra olika
datainsamlingar. Två av dessa (delstudie I och II) är intervjustudier och två är
enkätstudier (delstudie III och IV). Den sista (delstudie V) är en mer teoretisk
studie där sociala emotioner och empowerment diskuteras i kontexten
sjukskrivning, samt i hur man som sjukskriven upplever att man blivit bemött
och dess relation till återgång till arbete.
I avhandlingen har data således samlats in via både intervjuer och enkäter.
Materialet har analyserats genom kvalitativa och kvantitativa metoder.
Inledningsvis användes data från fokusgrupp intervjuer med personer med
erfarenhet av långtidssjukskrivning, där man frågat om faktorer som kan
påverka återgång till arbete. Materialet analyserades på ett explorativt och
beskrivande sätt. Resultaten låg till grund för mer riktade och detaljerade
individuella intervjuer om sjukskriva personers upplevelser av bemötande
från professionella. Intervjudata analyserades på ett induktivt och beskrivande
49
sätt. I en tredje delstudie analyserades svar på fyra frågor om upplevelser av
bemötande från professionella i en enkät om hälsa, arbete, och sjukfrånvaro
som skickades till sjukskrivna personer. De fyra frågorna analyserades genom
att använda logistisk regressions analys. Upplevelser av positivt bemötande
analyserades i relation till kön, ålder, födelseland och utbildningsnivå.
Resultaten från denna enkät samt från de två intervjustudierna användes för
att konstruera en mer detaljerad enkät om bemötande. Enkäten innehöll mer
riktade frågor om sjuskrivna personers upplevelser av bemötande från
professionella, vad detta bemötande väckt för känslor samt om bemötande
kan påverka återgång till arbete. Den skickades ut till långtidssjukskrivna
personer. Materialet analyserades genom att använda faktoranalys för att
gruppera olika faktorer av positivt bemötande samt multipel regressions
analys för att analysera upplevelse av bemötande relaterat till kön, ålder,
civilstånd, födelseland, utbildningsnivå, hel– eller deltidssjukskrivning,
självskattad hälsa, depression under de senaste åren samt orsak till
sjukskrivning.
I delstudie I framkom att sjukskrivna personer nämner bemötande från
professionella som en faktor som kan påverka återgång till arbete, trots att
intervjupersonerna inte tillfrågades om sådana möten. Delstudie II gav mer
detaljerad kunskap om olika aspekter av bemötande. Delstudie III visade att
deltagarna ansåg sig ha blivit mest positivt bemötta av professionella inom
hälso– och sjukvård, följt av försäkringskassa och företagshälsovård. Generellt
hade kvinnor, äldre, svensk födda och personer med högre utbildning skattat
bemötandet som mer positivt jämfört med män, yngre, utlandsfödda och
personer med lägre utbildning. Delstudie IV gav mer detaljerad kunskap om
olika aspekter av bemötande, samt visade på vissa skillnader i upplevelse av
bemötande och demografiska faktorer. Studien påvisade även att det fanns
vissa skillnader i hur sjukskrivna personer skattat bemötandet i relation till
professionella inom hälso- och sjukvården respektive försäkringskassan. I
delstudie V görs reflektioner till olika teorier inom sociala emotioner.
Kopplingar mellan empowerment, bemötande och sjukskrivning och återgång
till arbete lyfts fram och diskuteras.
Resultaten visar att positivt bemötande från professionella har många olika
dimensioner, och att möten mellan sjukskrivna personer och professionella är
en komplex process. Att t.ex. ha blivit respekterad och stöttad av
professionella framkom som betydelsefullt. Fynden är av central betydelse för
att få en ökad förståelse av hur bemötandet från professionella kan påverka
50
sjukskrivningsprocessen och återgång i arbete för sjukskrivna personer.
Kunskapen kan vara värdefull för att utveckla de strategier, färdigheter och
attityder som krävs av både professionella rehabiliteringsaktörer och
sjukskrivna personer för att påverka klienter att bemästra sin omgivning och
därigenom främja deras återgång i arbete. Ökad kunskap kring detta kan ligga
till grund för preventiva åtgärder t ex i form av utbildningsinsatser till
professionella, och därigenom en förbättrad arbetssituation för dessa och som
tidigare nämnts, främja återgång i arbete för sjukskrivna personer.
51
ACKNOWLEDGEMENTS
I wish to express my gratitude to everyone who helped and supported me
during the work underlying this thesis. In particular, I want to express my
sincere thanks to the following people:
The interviewees and the questionnaire participants for generously allowing
us to study their experiences of interactions with professionals.
My main supervisor, professor Kristina Alexanderson, for continuous support,
as well as creative and constructive criticism. Thank you for your neverending enthusiasm and for convincing me to always do the best I can.
Professor Tommy Svensson, my second supervisor, for inspiring support
especially during the design and analysis of the interview study. Thank you
for being the calmer and encouraging co-author I needed.
My co-authors, Elsy Söderberg, Karin Borg, Marianne Upmark, and Anders
Person. Elsy, for very valuable discussions and fine teamwork. Karin, without
you, the figures and values included in this thesis would not be
comprehensible. Marianne, for exchange of ideas during the final phase of the
last manuscript. Anders, for great help with statistics.
Ph.D. Ulla Gerner, Ph.D. Carl Edvard Rudebeck, Senior Lecturer Gunnel
Östlund, Professor Karin Ringsberg, Professor Ingemar Åkerlind, Ph.D. Barbro
Gustafsson, Docent Gunilla Krantz, and co-workers at the Section of Personal
Injury Prevention, Stockholm, for helpful comments on my papers and at
seminars.
Patricia Ödman for professional work with language revisions.
Kajsa Rothman for directing me through the bureaucracy of the university.
All co-workers at the Division of Social Medicine and Public Health for fruitful
discussions during coffee breaks. Particular thanks to Peter Garvin for being
the person who plops out nice comments when you least expected them, but
needed them most.
52
My mother-in-law, Gunborg, for being so understanding when days were
tough, for valuable tips about every day living, and for just spoiling the three
of us.
Helmut, my father-in-law for showing interest in my research and for giving
me advice about how to handle my role as a doctoral candidate.
My mother, Laila. Without knowing it, you helped me to finish this thesis
simply by not expecting great things from my research, especially during
periods when I was under a lot of pressure.
My father Arne. Thank you for always reminding me of the other reality going
on outside the academic world, and for great times with our four-footed
friends. My extra mother Berit, for being a good listener, and for always trying
to find solutions on small and great problems.
Urban, my brother, for never pretending you knew what I did at work.
All my gorgeous friends, relatives, and neighbours– thank you for the joy you
bring!
My beloved husband, Erik. You always support me and have the ability to
turn my burst of fury into more rewarding thoughts and actions. I am grateful
to you for your love and for all that we share together.
My precious son Oskar. You are my never ending source of strength and love.
Finally, thanks to my dog Loke for long, muddy and relaxing walks far away
from the world of research.
Financial support was provided by the Swedish Council for Working Life and
Social Research and the Swedish National Social Insurance Board.
Ulrika Müssener
Linköping 2007
53
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